1. Shock and Multisystem Failure

2. Shock
Can occur when any part of the cardiovascular system does not function properly for any reason
Begins with abnormal cellular metabolism that occurs when too little oxygen is delivered to tissues
Review of tissue perfusion
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3. Processes of Shock Initial stage (early shock)
Nonprogressive stage (compensatory stage)
Progressive stage (intermediate stage)
Refractory stage (irreversible stage)

4. Multiple Organ Dysfunction Syndrome
Cell damage is caused by the massive release of toxic metabolites and enzyme.
Metabolites trigger small clots to form that block tissue oxygenation and damage more cells, continuing the devastating cycle.
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5. Hypovolemic Shock
Occurs when low circulating blood volume causes a mean arterial pressure decrease; the body’s oxygen need is not met
Caused by external hemorrhage; common after trauma and surgery or reduction in levels of clotting factors
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6. Hypovolemic Shock (Continued)
Caused by internal hemorrhage as occurs with blunt trauma, gastrointestinal ulcers, and poor control of surgical bleeding

8. Cardiogenic Shock
Actual heart muscle is unhealthy and pumping is directly impaired.
Cardiac output and afterload are reduced, thus reducing mean arterial pressure.

10. Distributive Shock
Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability
Neural-induced distributive shock
Chemical-induced distributive shock
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12. Distributive Shock (Continued)
Anaphylaxis
Sepsis
Capillary leak syndrome

13. Obstructive Shock
Shock is caused by problems that impair the ability of the normal heart muscle to pump effectively.
Heart is normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.
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15. Physical Assessment/Clinical Manifestations
Cardiovascular changes
Pulse
Blood pressure
Oxygen saturation
Skin changes
Respiratory changes
Renal and urinary changes
Central nervous system changes
Musculoskeletal changes

16. Interventions Reverse the shock. Restore fluid volume.
Prevent complications through supportive and drug therapies.
Nonsurgical management includes oxygen therapy, fluid replacement, and monitoring.

17. Drug Therapies
Vasoconstrictors, such as dopamine, epinephrine, norepinephrine, phenylephrine
Agents that enhance contractility
Agents that enhance myocardial perfusion

18. Collaborative Management of Septic Shock
Manifestations of the first phase: unique to septic shock and often opposite from those seen with all other types of shock
Cardiovascular changes
Respiratory changes
Skin changes: in the hyperdynamic phase of septic shock, the skin is warm with no cyanosis evident
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19. Interventions for Septic Shock
Focus on correcting conditions causing shock and preventing complications.
Give oxygen therapy.
Drug therapy: antibiotics and anticoagulants, clotting factors and blood products, activated protein C, and antibodies, such as interleukin-1, interleukin-6, and tumor necrosis factor

20. Infusion Therapy

21. Parenteral Nutrition
Formulas: dextrose, protein, fat, vitamins, and numerous trace elements tailored to the specific metabolic needs of the client
Only used when the gastrointestinal tract cannot be used
Central
Peripheral
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22. Blood Transfusions and Other Components
Packed red blood cells
Platelets
Fresh frozen plasma
Albumin
Several specific clotting
factors

23. Medications
IV medications provide a rapid therapeutic effect but can also lead to immediate serious reactions.
Prescription for infusion therapy is necessary.

24. Vascular Access Device (VAD)
Short peripheral catheters
Superficial veins of the hand and forearm
Dwell for 72 to 96 hours and then require removal and insertion into another venous site
Complaints of tingling, feeling of “pins and needles” in the extremity, or numbness during the venipuncture can indicate nerve puncture.
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26. Midline Catheter
Catheter that is 6 to 8 inches long, inserted through veins of the antecubital fossa
Used for therapies lasting from 1 to 4 weeks
Should not be used for infusion of vesicant medications, which can cause tissue damage if they escape into the subcutaneous tissue (extravasation)

27. Peripherally Inserted Central Catheter (PICC)
Length ranges from 40 to 65 cm.
Basilic vein is the preferred site for insertion; cephalic vein can be used.
Placement is confirmed by chest x-ray examination.
No information is available on optimal dwell time.
Teach clients to perform normal ADLs, avoiding excessive physical activity.
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29. Nontunneled Percutaneous Central Catheter
Inserted through subclavian vein in the upper chest or jugular veins in the neck
Usually 15 to 20 cm long
Tip resides in the superior vena cava
Placement confirmed by chest x-ray examination
No recommendations
for optimal dwell time

30. Tunneled Central Catheter
A portion of the catheter lying in a subcutaneous tunnel separates the points at which the catheter enters the vein from where it exits the skin.
Tunneled central catheter is used for infusion therapy that is frequent and long-term.
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31. Implanted Port
Implanted ports consist of a portal body, a dense septum over a reservoir, and a catheter.
A subcutaneous pocket is surgically created to house the port body.
Port is usually placed in the upper chest or the upper extremity
Port needs to be flushed after each use and at least once a month between courses of therapy.
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33. Dialysis Catheter
Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells.
This catheter should not be used for administration of other fluids
or medications, except in an emergency.
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34. Infusion System Containers Administration sets Add-on systems
Needleless connection devices
Rate controlling devices:
Controller
Pumps
Syringe pumps
Ambulatory pumps

35. Catheter Care and Maintenance
Educating the client
Confirming tip location
Performing the nursing assessment
Securing and dressing the catheter
Changing administration sets and needleless connectors
Controlling infusion pressure
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36. Catheter Care and Maintenance (Continued)
Flushing the catheter
Obtaining blood samples from the catheter
Removing the catheter

37. Considerations for Older Adults
Skin care precautions
Vein and catheter selection
Cardiac and renal changes

38. Alternative Sites for Infusion
Arterial therapy
Intraperitoneal infusion
Subcutaneous infusion
Intraspinal infusion
Intraosseous therapy